Provider Demographics
NPI:1518712355
Name:SHORTRIDGE, DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:SHORTRIDGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W ADAMS AVE APT 1507
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1636
Mailing Address - Country:US
Mailing Address - Phone:317-697-8629
Mailing Address - Fax:
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program